This is a blog by a former CEO of a large Boston hospital to share thoughts about negotiation theory and practice, leadership training and mentoring, and teaching.

Thursday, October 19, 2006

Errors, Improvement, and Discipline

This posting is long, but I think the final point is very important, so please bear with me. Last year, one of our doctors violated one of our safety regulations, and although there was no harm to the patient, we disciplined him with a temporary suspension of privileges. The fact that we took this action ended up in the newspapers. Now, this doctor is one of the experts in his field and very well regarded in the region and often takes on cases that are so difficult that others will refuse to take them. A number of people in the hospital and from other hospitals contacted me about the case, wondering how we could treat such an exemplary doctor in such a manner. It occurred to me that the case would be an opportunity to remind everyone in our hospital about our standards and procedures, and I did so in the email that follows.

But after you quickly read my email, take the time to slowly read the one that I received from a nurse a day later. That's the message that really hits home.

Here's mine:

Dear Colleagues, I received a number of comments following last week's press report regarding disciplinary action against one of our physicians. Many of you were proud that you work in an organization that engages fully in the internal and external processes designed to improve care and ensure safety. However, some of you expressed surprise and concern and asked "Why couldn't this be limited to an internal process?" I thought it would be worthwhile to explain. We know that we all have the best of intentions in treating patients at BIDMC. In the vast majority of our hundreds of thousands of patient encounters each year, things go well. Every now and then, though, there is an unexpected adverse patient event or a near miss. This could result from a series of unexpected events that may be the fault of no one. Sometimes, though, it results from potentially avoidable medical error, a care process that does not work effectively enough to prevent errors, or from poor judgment of a member of our medical staff.Our Medical Executive Committee, comprising all of the departmental Chiefs and several other members of the physician staff, establishes rules of procedure and conduct that apply to medical care professionals here at the hospital. Those rules call for review of major adverse events and near misses whenever they occur. (Given industry experience, we can expect about four to six such episodes each month.) We conduct confidential peer reviews of these cases in the following manner: First, appropriate cases are identified at departmental conferences. These are then reported to our Department of Health Care Quality, where they are investigated to determine the root cause. We look for ways to learn from them and make improvements so we can better serve our patients. The vast majority of those reviews do not result in punitive action against a doctor. Indeed, we depend on healthcare professionals to disclose fully all facts so that the process can be accurate and helpful to future patients. As required by state law, the most serious of the adverse events are reported to the state Board of Registration in Medicine ("BORIM"). Some types of cases must be filed with the state Department of Public Health ("DPH"). The law states that the entire process at the BORIM is protected by the rules of confidentiality as a peer review event, but cases filed with the DPH are not confidential. There are other occasions, however, where a member of the medical staff may have willingly or knowingly violated one of the rules set forth by the Medical Executive Committee ("MEC"). Here, too, a confidential investigation is undertaken, whether that doctor is a full-time faculty member or any physician with privileges at our hospital. If there is a violation, the Chief of that service imposes a penalty that he or she deems appropriate. That case is then reviewed in its entirety by the Medical Executive Committee. Assisted by an internal peer review panel, the MEC can accept or modify the Chief's determination. The record of that case is then forwarded to the BORIM. The Board conducts it own review and takes it own action, which may be similar, more severe, or less severe than that taken by the Medical Executive Committee. It can assess a range of penalties, the ultimate one being a revocation of a license to practice. Unlike the adverse events reports, under state law, disciplinary actions are made public by the Board. We do not seek press coverage of these events, but actions by the state can generate media inquiries. When they do, we provide clear, open, and honest comments to reporters to help put the case in proper context. This series of processes is governed by the laws of the Commonwealth of Massachusetts. In the case of adverse events, those laws are designed to encourage disclosure by doctors by shielding them from unfair criticism and publicity during a substantive review of a case. The hope is to learn from our mistakes in a helpful and constructive environment. These reviews can often lead to resolving system problems, too. For example, the computerized physician order entry system was largely a response to illegible and incorrect written orders that resulted in medical errors. In the case of disciplinary actions, though, the laws are designed to publicize misbehavior -- to inform the public about the record of a doctor and to deter others from acting in the same manner. No one takes pleasure from a process in which a highly trained physician who has devoted his or her life to healing patients is put through the agony of this kind of publicity. On the other hand, the public has a right to know if a caregiver has acted in a manner inconsistent with the professional standards established by his or her peers. Men and women who choose to become doctors do so out of a great sense of service to their fellow human beings. The fact that we engage in intense review processes of our own colleagues is a sign of this quest for excellence. On those few occasions when a member of the medical staff is hurt or embarassed by this process, it is because his or her colleagues have acted to prevent patients from potential harm in the future. It is a sign of the strength and commitment of our Medical Center. It is also the law of the land, and we will abide by it. Sincerely, Paul

Now, here is the nurse's note to me:

I feel inclined to respond to your email with an experience I had today on the floor. Your email proved to be helpful in my circumstance. I am a new nurse at the hospital, and I am currently orienting. On my way to work early this morning I was thinking about the hospital and the recent publicity via this incident with the doctor. I actually felt a huge sense of pride coming into work. Taking the higher road is not always easy but lends it self to a freedom and power that all great institutions must embody. I believe that Beth Isreal's commitment to excellence is a model for both myself and other hospitals to emmulate. At work today I made a mistake, a medication error. My stomach turned, I felt faint . . . however I recalled my focus earlier in the day: on the integrity of the hospital and the type of light that it shined on my paradigm as I entered my day. I felt an immediate sense of freedom and put my attention on what I needed to do to correct the error. Although embarrassment and fear visited me, I wasn't overwhelmed by the emotions. I contacted the right people, and helped maintain the safety of my patient. It was a very challenging day . . . and I grew. I will go to sleep with integrity; knowing I was honest, feeling I had done all I could. I know healthcare presents these types of moral dilemas to all of us who choose this challenging field to work in. Beth Isreal is a safe place to honestly confront these dilemnas and strive to achieve the excellence that I know can exist. ** RN

I am curious about what this physician did, but I guess that isn't going to be revealed. I have had occasion to contact the hospital ombudsman several times and have basically been blown off. They say the doctor will be contacted, but that they are not allowed to tell me how the matter was resolved. This is frustrating to patients. They even passed a law here in AZ that says doctors can apologize to patients without the apology being used against them in a lawsuit. But they still don't--or won't.

But it's part of being accountable. Corporate honchos, police officers, air traffic controllers and the like are routinely and publicly held to account when something doesn't go as planned.

When I make a mistake, it's right there on the front page for everyone to see. Any reader is free to write a letter to the editor that criticizes my work or criticizes the newspaper's judgment, and more than likely that letter will be published.

I don't mind being held to a standard. It keeps me and my colleagues on our toes. Physicians should not mind being held to a public standard either. From personal experience, I can tell you: Nothing good ever comes from shrouding the bad in secrecy and equivocation.

There are certain parts of the review of medical cases that are assisted by the confidentiality of peer review. For one thing, it makes it more likely that a doctor or nurse will admit that he or she made a mistake. It is also makes it more likely that their peers will comment on the case with the unvarnished truth. This process results in both personal and systematic improvement in a medical center. That is why some parts of the medical improvement process are held in confidence.

But, there are certain things that are made public. For example, a disciplinary action of the sort described here is made public. Also, as noted in other parts of this blog, there is good reason to publish a doctor's or a hospital's clinical results, i.e, mortality and morbidity figures for the various types of medical procedures and treatments. That data does not accuse a doctor of anything. It just lets the public know how well he or she does in taking care of patients.

So, I guess what I am saying is that there are different kinds of accountability. Sometimes confidentiality is more effective in the long run. Sometimes public exposure of an individual's actions is more effective. Sometimes public disclosure of data is more effective.

Our job as a society is to decide which forms of accountability are most useful and appropriate. We do not want to be unduly punitive and adopt strategies that will cause uninetneded consequences -- but we also don't want to hold back when public exposure is the right remedy.

Your policy and process sounds exemplary. I wonder how long has it been in place and what effect, if any, has it had on malpractice litigation, the cost of settlements, and the hospital's cost for malpractice insurance?

Thanks, but I think our process is similar to most hospitals, at least here in Massachusetts. We have made no attempt to measure the effect of all this on malpractice cases or insurance costs. It is really designed mainly to improve patient quality and safety, in their own right. If there is some benefit in the malpractice arena, that is just icing on the cake.

We do have a strong risk management program, however, as part of our ownership and membership in CRICO, the captive insurance company that serves the Harvard hospitals, and the Risk Management Foundation, which provides excellent training to doctors, nurses, and others in the Harvard system.

The nurse's note moved me to tears. His/her bravery and commitment to integrity and good care, putting patient above self, are so good to see.

This is a precious thing, Paul. You, your team, and everyone everywhere who reads this should do everything they can to foster a world where people routinely do that.

I've known hospital staff who made honest human mistakes that had real consequences. It can be really, really hard to bear that knowledge. Sometimes I thank heaven that my work (writing and software) doesn't have that kind of consequence. I have the deepest respect for the people who've taken on the added responsibility of handling someone's health and even their survival.

It's so vitally important that people entering the field know that their ideals are not just airy concepts that will get trampled in politics. It's important that they know they can have a whole career of being committed to quality, service and integrity.

One more thought: the openness of this conversation makes it much more likely that I'll be compassionate with anyone who makes a mistake while caring for me.

I felt the same way, Dave, and you can imagine how I felt when the email arrived, just hours after i had sent out mine. Think about a young man or woman, say 24 or 25 years old, treating a wide variety of patients, and having the presence to reach the conclusions s/he did. It was one of the best things that I have experienced in the last 4 1/2 years.

"On the other hand, the public has a right to know if a caregiver has acted in a manner inconsistent with the professional standards established by his or her peers."

I agree with this wholeheartedly. Why, then, is most everything confidential? I would trust a hospital with an open and honest policy as opposed to those who "try" to cover it up. To cover it up plants the deep seed of mistrust with the patients and communities they serve.I would travel to your hospital, or MCG in Atlanta (featured on "Remaking American Medicine) before I'd ever set foot in a facility in the Texas Medical Center, which is only 20 minutes away. We trusted you when we came through those doors. Blindly. The attitude of "us vs them" is fostered by the facilities whose leaders fail to recognize their shortcomings, and treat the patient and the family as their enemy. You are setting the example and I hope your patient satisfaction and census' continue to escalate as a result.

Thanks. This is actually very hard to do well, and as I have noted, some aspects should remain confidential to ensure that a robust peer review process takes place. There is a wide range of opinion, beyond that, as to what should be public and what should not. I will return to this topic again when I post a section on apologies.